[Comparison of accuracy between robot-assisted and fluoroscopy-guided percutaneous pedicle screw placement for treatment of lumbar spondylolisthesis]

[Clinical application of percutaneous pedicle screw placement guided by ultrasound volume navigation combined with X-ray fluoroscopy: a prospective randomized controlled study]

Objective

To explore the feasibility and accuracy of ultrasound volume navigation (UVN) combined with X-ray fluoroscopy-guided percutaneous pedicle screw implantation through a prospective randomized controlled study.

Methods

Patients with thoracic and lumbar vertebral fractures scheduled for percutaneous pedicle screw fixation between January 2022 and January 2023 were enrolled. Among them, 60 patients met the selection criteria and were included in the study. There were 28 males and 32 females, with an average age of 49.5 years (range, 29-60 years). The cause of injury included 20 cases of traffic accidents, 21 cases of falls, 17 cases of slips, and 2 cases of heavy object impact. The interval from injury to hospital admission ranged from 1 to 5 days (mean, 1.57 days). The fracture located at T 12 in 15 cases, L 1 in 20 cases, L 2 in 19 cases, and L 3 in 6 cases. The study used each patient as their own control, randomly guiding pedicle screw implantation using UVN combined with X-ray fluoroscopy on one side of the vertebral body and the adjacent segment (trial group), while the other side was implanted under X-ray fluoroscopy (control group). A total of 4 screws and 2 rods were implanted in each patient. The implantation time and fluoroscopy frequency during implantation of each screw, angle deviation and distance deviation between actual and preoperative planned trajectory by imaging examination, and the occurrence of zygapophysial joint invasion were recorded.

Results

In terms of screw implantation time, fluoroscopy frequency, angle deviation, distance deviation, and incidence of zygapophysial joint invasion, the trial group showed superior results compared to the control group, and the differences were significant ( P<0.05).

Conclusion

UVN combined with X-ray fluoroscopy-guided percutaneous pedicle screw implantation can yreduce screw implantation time, adjust dynamically, reduce operational difficulty, and reduce radiation damage.

[A comparative study of robot-assisted and freehand pedicle screw placement in upper thoracic surgery]

Objective

To compare the safety and accuracy of pedicle screw placement assisted by robot system with freehand pedicle screw placement in upper thoracic surgery.

Methods

Between December 2017 and December 2019, 39 cases with upper thoracic pedicle screw internal fixation were included in the study, including 19 cases in robot group (group A, robot assisted pedicle screw placement) and 20 cases in freehand group (group B, freehand pedicle screw placement). There were 104 screws implanted in group A and 108 screws in group B. There was no significant difference in age, gender composition, body mass index, disease type, number of screws implanted, and segmental distribution between the two groups ( P>0.05). The operation time, intraoperative blood loss, and postoperative drainage were recorded and compared between the two groups. CT scan was performed in all patients at 2 days after operation to evaluate the screw accuracy based on the Gertzbein-Robbins grading standard.

Results

The operation time of group A was significantly longer than that in group B ( t=2.759, P=0.009). There was no significant difference in intraoperative blood loss and postoperative drainage between the two groups ( t=-0.796, P=0.431; t=-0.814, P=0.421). At 2 days after operation, according to Gertzbein-Robbins grading standard, the accuracy of pedicle screw implantation in group A were grade A in 94 screws, grade B in 9 screws, and grade C in 1 screw; and in group B were grade A in 72 screws, grade B in 26 screws, grade C in 9 screws, and grade D in 1 screw; the difference between the two groups was significant ( Z=4.257, P=0.000). The accuracy rate of group A was 99.04%, and that of group B was 90.74%, showing significant difference ( χ ²=7.415, P=0.006).

Conclusion

Compared with traditional freehand pedicle screw placement, robot-assisted pedicle screw placement significantly improves the accuracy and safety of screw placement without increasing the bleeding and postoperative drainage.

[A comparative study on treatment of lumbar degenerative disease with osteoporosis by manual and robot-assisted cortical bone trajectory screws fixation]

OBJECTIVE

To compare the safety and accuracy of manual and robot-assisted cortical bone trajectory (CBT) screws fixation in the treatment of lumbar degenerative diseases with osteoporosis.

METHODS

The clinical data of 58 cases of lumbar degenerative disease with osteoporosis treated by CBT screw fixation between February 2017 and February 2019 were analyzed retrospectively. Among them, 29 cases were fixed with CBT screws assisted by robot (group A), 29 cases were fixed with CBT screws by hand (group B). There was no significant difference between the two groups in terms of gender, age, body mass index, lesion type, T-value of bone mineral density, and operative segment ( P>0.05), with comparability. The accuracy of implant was evaluated by Kaito's grading method, and the invasion of CBT screw to the superior articular process was evaluated by Babu's method.

RESULTS

The operation time and intraoperative blood loss in group A were significantly less than those in group B ( t=-8.921, P=0.000; t=-14.101, P=0.000). One hundred and sixteen CBT screws were implanted in the two groups. At 3 days after operation, according to the Kaito's grading method, the accuracy of implant in group A was 108 screws of grade 0, 6 of grade 1, and 2 of grade 2; and in group B was 86 screws of grade 0, 12 of grade 1, and 18 of grade 2; the difference was significant ( Z=4.007, P=0.000). There were 114 accepted screws (98.3%) in group A and 98 (84.5%) in group B, the difference was significant ( χ 2=8.309, P=0.009). At 3 days after operation, according to Babu's method, there were 85 screws in grade 0, 3 in grade 1, and 2 in grade 2 in group A; and in group B, there were 91 screws in grade 0, 16 in grade 1, 5 in grade 2, and 4 in grade 3; the difference was significant ( Z=7.943, P=0.000). No serious injury of spinal cord, nerve, and blood vessel was found in the two groups. One patient in group A had delayed cerebrospinal fluid leakage, and 2 patients in group B had mild anemia. Both groups were followed up 10-14 months (mean, 11.6 months). The neurological symptoms were improved, and no screw loosening or fracture was found during the follow-up.

CONCLUSION

Compared with manual implantation of CBT screw, robot-assisted spinal implant has higher accuracy, lower incidence of invasion of superior articular process, and strong holding power of CBT screw, which can be applied to the treatment of lumbar degenerative diseases with osteoporosis.

[Robot-guided percutaneous kyphoplasty in treatment of multi-segmental osteoporotic vertebral compression fracture]

Objective

To evaluate the safety and effectiveness of robot-guided percutaneous kyphoplasty (PKP) in treatment of multi-segmental thoracolumbar osteoporotic vertebral compression fracture (OVCF).

Methods

A clinical data of 63 cases with multi-segmental thoracolumbar OVCF without neurologic deficit treated with PKP between October 2017 and February 2019 were analyzed retrospectively. The patients were divided into robot-guided group (33 cases) and traditional fluoroscopy group (30 cases). There was no significant difference in gender, age, fracture segment, bone mineral density, and preoperative visual analogue scale (VAS) score, midline vertebral height, and Cobb angle between the two groups ( P>0.05). The time to establish the tunnel, the times of fluoroscopy, the dose of fluoroscopy, the deviation of puncture, the distribution of bone cement, the leakage of bone cement, the puncture angle, and the postoperative VAS score, midline vertebral height, and Cobb angle were recorded and compared.

Results

The patients in two groups were followed up 11-13 months (mean, 12 months). Compared with traditional fluoroscopy group, the time to establish the tunnel, the times and dose of fluoroscopy in robot-guided group were significantly lower, the deviation of puncture was slighter, the distribution of bone cement was better, and the puncture angle was larger, the differences between the two groups were significant ( P<0.05). There were 8 segments (9.3%, 8/86) of bone leakage in robot-guided group and 17 segments (22.6%, 17/75) in traditional fluoroscopy group, the difference between the two groups was significant ( χ ²=5.455, P=0.020). There was no significant difference in VAS score, the midline vertebral height, and Cobb angle between the two groups at 2 days after operation and last follow-up ( P>0.05).

Conclusion

Robot-guided PKP in treatment of multi-segmental thoracolumbar OVCF can shorten the operation time, improve the accuracy of puncture, reduce the times and dose of fluoroscopy, reduce the leakage of bone cement, and achieve better cement distribution.

[Comparative study on effectiveness of modified-transforaminal lumbar interbody fusion and posterior lumbar interbody fusion surgery in treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients]

OBJECTIVE

To compare the effectiveness of modified transforaminal lumbar interbody fusion (modified-TLIF) and posterior lumbar interbody fusion (PLIF) for mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients.

METHODS

The clinical data of 106 patients with mild to moderate lumbar spondylolisthesis (Meyerding classification≤Ⅱ degree) who met the selection criteria between January 2015 and January 2017 were retrospectively analysed. All patients were divided into modified-TLIF group (54 cases) and PLIF group (52 cases) according to the different surgical methods. There was no significant difference in preoperative clinical data of gender, age, disease duration, sliding vertebra, Meyerding grade, and slippage type between the two groups ( P>0.05). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, hospital stay, and complications of the two groups were recorded and compared. The improvement of pain and function were evaluated by the visual analogue scale (VAS) score and Japanese Orthopedic Association (JOA) score at preoperation, 1 week, and 1, 6, 12 months after operation, and last follow-up, respectively. The effect of slip correction was evaluated by slip angle and intervertebral altitude at preoperation and last follow-up, and the effectiveness of fusion was evaluated according to Suk criteria.

RESULTS

All patients were followed up, the modified-TLIF group was followed up 25-36 months (mean, 32.7 months), the PLIF group was followed up 24-38 months (mean, 33.3 months). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, and hospital stay of the modified-TLIF group were significantly less than those of the PLIF group ( P<0.05). The VAS score and JOA score of both groups were significantly improved at each time point after operation ( P<0.05); the scores of the modified-TLIF group were significantly better than those of the PLIF group at 1 and 6 months after operation ( P<0.05). The slip angle and intervertebral altitude of both groups were obviously improved at last follow-up ( P<0.05), and there was no significant difference between the two groups at preoperation and last follow-up ( P>0.05). At last follow-up, the fusion rate of the modified-TLIF group and the PLIF group was 96.3% (52/54) and 98.1% (51/52), respectively, and no significant difference was found between the two groups ( χ 2=0.000, P=1.000). About complications, there was no significant difference between the two groups in nerve injury on the opposite side within a week, incision infection, and pulmonary infection ( P>0.05). No case of nerve injury on the operation side within a week or dural laceration occurred in the modified-TLIF group, while 8 cases (15.4%, P=0.002) and 4 cases (7.7%, P=0.054) occurred in the PLIF group respectively.

CONCLUSION

Modified-TLIF and PLIF are effective in the treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients. However, modified-TLIF has relatively less trauma, lower blood loss, lower drainage volume, lower incidence of dural laceration and nerve injury, which promotes enhanced recovery after surgery.

[Short-term effectiveness comparison between robotic-guided percutaneous minimally invasive pedicle screw internal fixation and traditional open internal fixation in treatment of thoracolumbar fractures]

OBJECTIVE

To compare short-term effectiveness between robot-guided percutaneous minimally invasive pedicle screw internal fixation and traditional open internal fixation in the treatment of thoracolumbar fractures.

METHODS

The clinical data of 52 cases of thoracolumbar fracture without neurological injury symptoms admitted between January 2018 and May 2018 were retrospectively analyzed. According to the different surgical methods, they were divided into minimally invasive group (24 cases, treated with robot-assisted percutaneous minimally invasive pedicle screw internal fixation) and open group (28 cases, treated with traditional open internal fixation). There was no significant difference between the two groups in the general data such as gender, age, cause of injury, fracture segment, thoracolumbar injury classification and severity score (TLICS), preoperative back pain visual analogue scale (VAS) score, Oswestry disability index (ODI) score, fixed segment height, and fixed segment kyphosis Cobb angle ( P>0.05). The operation time, intraoperative blood loss, and hospitalization time of the two groups were recorded and compared; as well as the VAS score, ODI score, fixed segment height, and fixed segment kyphosis Cobb angle of the two groups before operation and at 3 days, 1 month, 6 months, and 10 months after operation. CT scan was reexamined at 1-3 days after operation, and the pedicle screw insertion accuracy rate was determined and calculated according to Gertzbein-Robbins classification standard.

RESULTS

The operation time of the minimally invasive group was significantly longer than that of the open group, but the intraoperative blood loss and hospitalization time were significantly shorter than those of the open group ( P<0.05). There were 132 pedicle screws and 158 pedicle screws implanted in the minimally invasive group and the open group respectively. According to the Gertzbein-Robbins classification standard, the accuracy of pedicle screws was 97.7% (129/132) and 96.8% (153/158), respectively, showing no significant difference between the two groups ( χ 2=0.505, P=0.777). The patients in both groups were followed up 10 months, and there was no rejection or internal fixation fracture. In the minimally invasive group, the internal fixator was removed at 10 months after operation, but not in the open group. The VAS score, ODI score, fixed segment heigh, and fixed segment kyphotic Cobb angle of the two groups were improved in different degrees when compared with preoperative ones ( P<0.05). Except that the VAS score and ODI score of the minimally invasive group were significantly better than those of the open group at 3 days after operation ( P<0.05), there was no significant difference between the two groups at other time points ( P>0.05).

CONCLUSION

Robot-assisted percutaneous minimally invasive pedicle screw internal fixation for thoracolumbar fractures has significant advantages in intraoperative blood loss, hospitalization time, and early postoperative effectiveness and other aspects, and the effect of fracture reduction is good.

[A comparative study of spinal robot-assisted and traditional fluoroscopy-assisted percutaneous reduction and internal fixation for single-level thoracolumbar fractures without neurological symptoms]

OBJECTIVE

To compare the effectiveness and screw planting accuracy of percutaneous reduction and internal fixation with robot and traditional fluoroscopy-assisted in the treatment of single-level thoracolumbar fractures without neurological symptoms.

METHODS

The clinical data of 58 patients with single-level thoracolumbar fractures without neurological symptoms between December 2016 and January 2018 were retrospectively analysed. According to different surgical methods, the patients were divided into group A (28 cases underwent robot-assisted percutaneous reduction and internal fixation) and group B (30 cases underwent fluoroscopy-assisted percutaneous reduction and internal fixation). There was no neurological symptoms, other fractures or organ injuries in the two groups. There was no significant difference in general data of age, gender, fracture location, AO classification, time from injury to surgery, and preoperative vertebral anterior height ratio, sagittal Cobb angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI) score between the two groups ( P>0.05). The screw placement time, operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, hospitalization time, operation cost, postoperative complications, VAS score, ODI score, anterior vertebral height ratio, and sagittal Cobb angle before operation, at 3 days, 6 months after operation, and at last follow-up were recorded and compared between the two groups. The accuracy of the pedicle screw placement was evaluated by Neo's criteria.

RESULTS

The screw placement time, operation time, and intraoperative fluoroscopy frequency of group A were significantly less than those of group B, and the operation cost was significantly higher than that of group B ( P<0.05). But there was no significant difference in intraoperative blood loss and hospitalization time between the two groups ( P>0.05). Both groups were followed up 12-24 months, with an average of 15.2 months. The accuracy rate of screw placement in groups A and B was 93.75% (150/160) and 84.71% (144/170), respectively, and the difference was significant ( χ 2=5.820, P=0.008). Except for 1 case of postoperative superficial infection in group A and wound healing after dressing change, there was no complication such as neurovascular injury, screw loosening and fracture in both groups, and there was no significant difference in the incidence of complications between the two groups ( χ 2=0.625, P=0.547). The anterior vertebral height ratio, sagittal Cobb angle, VAS score, and ODI score of the two groups were significantly improved ( P<0.05); there was no significant difference between the two groups at all time points after operation ( P>0.05).

CONCLUSION

The spinal robot and traditional fluoroscopy-assisted percutaneous reduction and internal fixation can both achieve satisfactory effectiveness in the treatment of single-level thoracolumbar fractures without neurological symptoms. However, the former has higher accuracy, fewer fluoroscopy times, shorter time of screw placement, and lower technical requirements for the operator. It has wide application potential.